Personal Information

Full Name *

Date of Birth *

Age *

Sex Assigned at Birth

Gender Identity

Preferred Pronouns

Occupation

Email *

Phone *

Home Address

Preferred Contact Method

Phone

Text

Email

Mail

Emergency Contact Name

Relationship

Emergency Contact Phone

Health and Wellness Goals

What are your health and wellness goals? Why are they important to you?

Personal Health and Family History

What's the most important thing you'd like to share about your health story?

Primary care provider

Other physicians or specialists

Practitioners, therapists, healers, etc.

Please list any supplements or medications you take

Have you experienced any barriers or challenges to accessing healthcare?

Medical Information

Medical diagnoses or conditions

History of serious illnesses, hospitalizations, injuries, or surgeries

Family History

Describe the health of your Mother

Describe the health of your Father

Is there anything from your childhood pertaining to your health you'd like to share?

Do you have any other notable family or personal health information you'd like to share?

Physical Health Information

Current Weight

Height

Sleep

How many hours do you sleep per night on average?

How would you describe your quality of sleep?

How is your energy level most days?

Very Low

1

2

3

4

5

Very High

Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain:

Nutrition Information

What foods did you grow up eating?

How would you describe your past relationship or history with food? Do any specific memories about food or eating come to mind?

Describe your current relationship with food.

Do you have any food allergies or intolerances? If so, please list:

Do any of the following apply to you?

Challenges with Preparing Meals

Difficulties Chewing or Swallowing

Challenges with Access to Food

Poor Appetite

Do you regularly use any of the following?

Alcohol

Tobacco Products

Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain:

What does a typical day of eating look like for you?

Breakfast

Lunch

Dinner

Snacks

What, if anything, would you like to change about your nutrition?

Mental and Emotional Health Information

How would you describe your overall mental and emotional health?

How do you like to support your mental health?

How do you cope with stress?

Spiritual Health Information

What role does spirituality play in your life, if any?

Lifestyle Information

What are the important relationships in your life?

Is there anything you'd like to share about your social life? If so, please explain:

Who do you live with, if anyone?

How many hours per week do you typically work?

What hobbies or recreational activities do you enjoy?

What role does movement, including sports, exercise, and physical activity, play in your life?

Additional Comments

Is there anything else you'd like to share?

Health History Form